Fully Robotic Sleeve Gastrectomy Using Complete Gastric Staple Line Bioabsorbable Reinforcement: How I Do It (a Video).

Robotic sleeve gastrectomy (RSG) is gaining place among surgeons. In our initial RSG practice, we noticed that gastric staple line intraoperative bleeding is more frequent and more important compared to the conventional laparoscopic approach. Any technique that could reduce the likelihood of intraoperative bleeding in RSG would be of tremendous benefit. The present video report is a detailed description of a fully RSG using complete gastric staple line bioabsorbable reinforcement, minimizing intraoperative bleeding. We present the case of a 32-year-old female patient with severe obesity (weight = 132 kg; BMI = 46.8 kg/m2) that underwent fully RSG in our department. RSG technique is thoroughly described, highlighting several important aspects of RSG, including (i) patient positioning to optimize access and ergonomics; (ii) the use of a Nathanson liver retractor, avoiding interference with robotic arms; (iii) trocar placement strategy; (iv) intraoperative selection of stapler reloads; and (v) the use of a bioabsorbable reinforcement (Seamguard®, Gore) for staple line reinforcement and bleeding minimization. Operative time was 180 min, and, blood loss was minimal (< 10 ml). The patient was discharged on postoperative day 1. Postoperative recovery was uneventful, without bleeding, gastric leak, or other complications. Only simple oral analgesics were required postoperatively. At 1-month follow-up visit, the patient had lost 10 kg and reported significant improvement in overall health. Complete gastric staple line bioabsorbable reinforcement seems to decrease intraoperative bleeding when the robotic approach is used for sleeve gastrectomy. Prospective randomized studies are needed to validate this approach as gold standard practice for RSG.